3 CHAPTER 1 Introduction Achieving Meaningful Use 1 Quality Reporting Services and Quality Submission Services 2 Crystal Reports templates for Meaningful Use reporting 3 Report template features 5 Achieving Meaningful Use Centricity EMR includes functional and quality measure reports based on final ONC (Office of the National Coordinator for Health Information Technology) criteria as well as National Quality Forum (NQF) reports. The release is ONC-ATCB certified and includes features and functionality designed to successfully demonstrate meaningful use as specified in the CMS Electronic Health Records (EHR) Incentive Program. For a high-level summary of functional measures linked to new features in this release and supporting reports, see What s New in Centricity EMR version 9.5 in your documentation library. This guide highlights those product features that support reporting for Meaningful Use measures. There are two parts to achieving Meaningful Use: Part 1 involves certified EHR technology in a meaningful way as defined in both the functional and quality measure specifications. Part 2 requires organizations to apply to participate in the EHR Incentive Program and to attest to (and report on) using certified EHR technology within a defined period of time. GE Healthcare offers Web-based reporting and data submission services designed to assist your organization in achieving Meaningful Use. For details, see Quality Reporting Services and Quality Submission Services on page 2. Quality Reporting Services are hosted by the Medical Quality Improvement Consortium (MQIC). Membership in MQIC is not required to use these services, however as an MQIC member you receive Quality Reporting Services at no extra charge and your data are prepopulated in the reporting templates. GE also provides optional Crystal Reports templates described in this guide that you can use within the application. The templates provide basic reporting for Meaningful Use functional and quality measures, however some may need to be customized by a qualified Crystal Reports designer to meet your organization s reporting needs.

4 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Quality Reporting Services and Quality Submission Services Quality Reporting Services provides reports and services to assist you in evaluating your organization s ability to meet quality measurements, including all required and optional Meaningful Use reporting requirements. GE Healthcare processes data you collect for quality measures so you can avoid costly data and report design. Your de-identified data are processed by a secure data warehouse and made available in reports via a Web portal your quality administrators and providers can access. They can also drill down from the enterprise to clinic and provider levels and customize reports. As part of these services, GE Healthcare also provides clinical analysts who can help you understand quality measures and how to improve the data your clinicians collect. Quality Submission Services (not available yet) will submit data to third parties such as CMS on behalf of your organization, for programs such as Meaningful Use, PQRI, or the erx Incentive. When used in conjunction with Quality Reporting Services, data are automatically generated in the required format for clinical functional and quality measures. Currently this service is not available because the EHR Incentive Program cannot receive attestation submissions electronically yet. Quality Submission Services is part of our certified EHR solution. You only pay for this service after electronic submission, beginning in 2012 for Meaningful Use. Your organization is solely responsible for determining whether your Eligible Professionals meet the requirements for Meaningful Use and ensuring the accuracy of any Meaningful Use attestation. Ensure you understand the measure requirements, reporting functionality and that you monitor the quality of the data entered into the application. To schedule a demo of Quality Reporting Services, Performance Reporting, or the MQIC program, or for more information on how to enroll, contact Centricity Services or your Value-Added Reseller or send to 2

5 Crystal Reports templates for Meaningful Use reporting Crystal Reports templates for Meaningful Use reporting GE offers basic Crystal Reports templates with Crystal Parameters to gather data meeting Meaningful Use measures within the Reports module.!!! These are report templates only. They search your data with commonly used observation terms and document types. You may need to modify the reports if you use custom observation terms or documents. Due to significant changes in the database to support report ease of use and reporting performance, these reports cannot be used in earlier versions of the application. Crystal Reports for Meaningful Use are not recommended for all customers. Your organization is solely responsible for determining whether your Eligible Professionals meet the requirements for Meaningful Use and ensuring the accuracy of any Meaningful Use attestation. Ensure you understand the measure requirements, reporting functionality and that you monitor the quality of the data entered into the application. Depending on the database size and the amount of data that is being searched, certain reports take a very long time to run, which may not be workable within your environment. To test whether your database size is consistent with using Crystal Reports templates for Meaningful Use measurements, use the following database scripts and the algorithm. 3

6 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Find database size Four factors determine database size: users, documents, observations, and audit events. Run the following four database queries using a SQL database query tool: Users select count(*) from usr where isrespprov = 1 Documents select count(*) from document Observations select count(*) from obs Audit Events select count(*) from audit_event Add queries output and divide by 10 million (10,000,000): Users + Documents + Observations + Audit Events = DB size Check table below to see whether your database size will work with Crystal Reports Templates for Meaningful Use: Database size # reports running over 2 hrs #reports running less than 2 hrs If your database size is in the yellow or red zones, Quality Reporting Services will be your best option based on run time performance of the Crystal Reports. All customers will benefit from using Quality Reporting Services. Reporting is easy and flexible. 4

7 Report template features Accessing and running reports Report template features Installation instructions are located in the Meaningful Use Reports Release Notes available at All reports are located in the Centricity EMR 95/crwpt folder and run from the Reports Print window. You can customize report parameters in Setup Settings > Reports > Reports.The reports can also be modified outside the application in Crystal Reports. Important. If reports will be accessed from multiple locations of care, copy the folder to a central user-accessible location on your network. If you customize reports, GE recommends you rename these reports or move them to a different folder so that your customizations are preserved if you import a later version of the reports clinical kit. Configuration This section describes the basic Report template features. Quality Reporting Services reports have similar features and settings that are accessed on the Quality Report Services Web site. Some items, such as file name, only apply to Crystal Reports. In each report you specify a reporting period with start and end dates. You can also select Locations of Care. To add other custom parameters go to Setup Settings > Reports > Reports. When running reports, remember that eligible providers may have relevant data in more than one authorized location. 5

8 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Display format Most reports display measured data for users (by user) with a description of the measure and how it was calculated. Each report includes three sections: Header - Includes measure title, reporting period, and CMS-specified measure description Details - Lists users associated with measured data, numerator and denominator counts, calculated percentage, and an indication when a user has not met the measure threshold. For measures with an exclusion, the report includes the exclusion count and an indication when the user meets the exclusion. Footer - Includes (at a minimum) when the report was printed and a report version number on the first page of the report. Header Details Excluded/Not Met indicators Users counted Numerator/denominator counts per provider Percentage met by provider Footer When you attest, remember to save and archive all reports in PDF format for future reference. Eligible Provider (EP) Meaningful Use is based on attestation by eligible providers, so the reports return data grouped by provider. For encounter- and patient-based reports, the provider is the user who is the responsible provider for a document or its appends. 6

9 Seen by Eligible providers serving as preceptors Reports link eligible providers to measured activities when they are the responsible provider for a document or its appends. You can include encounters documented in a residency workflow where a preceptor is signing off on a resident s document. Quality Reporting Services reports look for both the responsible provider of the document and the first signing provider on the document. Crystal Reports templates only looks for responsible providers. GE recommends that eligible providers serving as preceptors either be the responsible provider for the resident s document or, for Crystal Reports, the responsible provider for an append to the document. Reports may include individuals who are not eligible providers, if the eligible provider s name is on an append to the document. Seen by Most reports are based on the term seen by used in many Meaningful Use measures. In the application, this might be an encounter or other direct interaction with a patient that you bill E&M codes for, including those with standard document types of office visit or procedure, or where applicable, home care or psychiatric visits. Seen by in Quality Reporting Services reports Seen by in Crystal Reports In addition to the standard document types of Office Visit, Office Procedure, Home Care, or Psychiatric Visits, MQIC considers custom document types that can map to the standard types. In some cases, more than one Eligible Provider can include the same encounter in their counts. The reports look for: Responsible Provider for a qualifying document within the measure reporting period. First Signing Provider for a qualifying document within the measure reporting period. Appended documents are not considered part of the Meaningful Use seen by criteria. In Crystal Reports, a patient is seen when a document type that represents an office visit, office procedure, or home care report, is signed in her chart. The date of the visit is the date of the document. This is the date that must be within the measure reporting period, not the signed date. To include documents capturing this array of encounters, the reports use the database view MU_PATIENT_PROVIDER, that automatically returns information for documents and their appends based on a global chart document view called Patient Encounter (MU). 7

10 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Modifying the Patient Encounter (MU) document view This global chart document view is hidden by default but can be modified in Setup > Settings > Chart > Document Views. The view includes the document types Office Procedure, Office Visit, and Home Care Report. If you have other custom document types that capture patient encounters you can add them here, as shown in the following illustration. Users need not include the view in their preferred views for their data to be counted. DO NOT check All types option to include all document types Important. If you check this option to add all document types your reports will not return useful data. This option overrides system settings reports rely on to gather data. If you manually include document types that 8

11 Organization of reports Organization of reports Crystal report data definitions are not patient encounters, report data returned for providers is not calculated correctly. Filed in Error or Replaced document types cannot be included Filed in Error or Replaced document types cannot be added to the Patient Encounter (MU) view. Checking the options does not add them to the report. One or more providers can determine seen by Users who fulfill certain conditions in relation to a patient encounter determine whether a document for a patient is counted for a provider. In some cases, more than one provider can include the same encounter in their counts. The reports look for the Responsible provider for a qualifying document within the measurement period. Meaningful Use reports are located in the CRWRPTS folder in the client application program files. However, they are accessed from two folders in the Reports module. CMS Functional Measures - reports are organized into sub-folders for required (Core) and optional (Menu) functional measures. CMS Quality Measures - reports are organized into sub-folders for required (Core, Alternate Core) and optional (Menu) quality measures. Report names in the user interface include the measure number and descriptive name. File names are designed to make them easy to identify by measure number, category, and short name. There are no reports for measures that require self-attestation. Title - This is the printed report title which differs from the report label in Report Print screen. The CMS regulation that governs this measure is displayed below. Objective - CMS definition of what it is to be achieved by using certified EHR technology. Measure - CMS definition of how the objective is measured, including the minimum threshold to qualify for the Meaningful Use incentive. Exclusion - CMS definition of when eligible providers are exempt from meeting the minimum threshold. 9

12 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 10

15 CMS Functional Measures - Core 01 CPOE for Medication Orders - All Active Medications (Core) Source Objective Measure Exclusion References Description File name Denominator Numerator 42 CFR 495.6(d)(1) Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE. Any EP who writes fewer than 100 prescriptions during the EHR reporting period. EHR Incentive Program Specification: Percentage of patients seen in the reporting period who had at least one active medication on their medication list and for whom a licensed healthcare professional used CPOE to generate a prescription at least once during the reporting period. MU_Stg1_01_FC_CPOEMedOrders.rpt Count 1 for every patient seen by the eligible provider and where the patient's chart has at least one active medication. seen by - see Seen by on page 7, for QRS and Crystal Reports. active medication - Any medication recorded in the chart that is a coded drug (and not DME). The onset date must either be blank or on or before the last day of the measure reporting period; if there is an end date, it must be on or after the first day of the measure reporting period. QRS report - Uncoded medications may be converted to coded medications if a free text medication entry can be mapped to a coded medication. Of the patients in the denominator, count 1 for every patient where the patient's chart has at least one prescription that was a CPOE medication order, signed by a qualifying user within the measurement period. CPOE medication order - A prescription for a coded medication (and not a DME) entered into the chart during the reporting period using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone. qualifying user - Equivalent to the CMS term licensed healthcare professional. In the application, this is indicated by the user s assigned Job Title. licensed healthcare professional - The signed by user's Job Title in the application must contain one of the following words at the time the measure report is printed: License, Physician, Resident, Medical Director, or Nurse. QRS report - Whether a provider is considered a licensed healthcare professional is assessed on the last extract date during the reporting period, which is at the end of the reporting period by default. 13

16 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Exclusion Count 1 for every prescription for a coded medication (not DME) that was entered as a medication order and written by the eligible provider during the measurement period. written by - Eligible provider is the user selected as Authorized By for the prescription. medication order - A prescription for a coded medication (and not a DME) entered into the chart using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone or Handwritten. Note: If the exclusion count is less than 100, the status column in the report will say "excluded." Setup, workflows, and best practices Setup 1 Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Workflow 2 Confirm or modify user Job Titles. If necessary, you can create new or modify existing Job Titles and assign them to providers to capture all licensed providers in your organization. Go to Setup > Settings > System > Users > Job Titles. 3 Customize report template. If necessary, modify user job title selection criteria to include custom job titles or search for additional strings. Prescribe medication, Refill medication, Remove medication This measure focuses on patients who came into the office for a visit and were seen by a provider. The measure considers prescriptions produced for a patient during their visit. Since most application workflows related to a patient office visit include the provider signing prescriptions and refills for that patient, those workflows support this measure. This measure does not consider refill requests that come in by fax or phone or electronically if the patient has not been seen during the reporting period. Best Practice Note that User who enters the prescription record does not have to be a licensed healthcare professional User who signs the prescription must be a licensed healthcare professional To receive MU credit, an eligible provider must be the Authorizing Provider on the prescription These prescribing methods do not qualify as CPOE-defined prescribing methods: Handwritten, Samples Given, Refax, Reprint, Historical. While many organizations have standard policies regarding refilling medications and producing prescriptions, this Meaningful Use measure identifies the licensed healthcare professional as someone who can sign/send/print the order/prescription. 14

17 CMS Functional Measures - Core 01 CPOE for Medication Orders - Prescribed Medications Only (Core) Source Objective Measure Exclusion References Description File name Denominator 42 CFR 495.6(d)(1) Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE. Note: This alternate report may be used only by eligible providers who under the following circumstances are both unable to meet the measure and unable to qualify for the exclusion. A qualifying eligible provider Prescribes more than 100 medications during the EHR reporting period Maintains medication lists that include medications that they did not order Orders medications for less than 30 percent of patients with a medication in their medication list during the EHR reporting period For additional details, see CMS FAQ 1063 at Providers meeting all three criteria...may limit their denominator to only those patients for whom the eligible provider has previously ordered medication, if they so choose. Eligible providers who do not meet the three criteria listed above must still base their calculation on the number of unique patients with at least one medication in their medication list seen by the eligible provider during the EHR reporting period regardless of who ordered the medication or medications in the patient's medication list. Any EP who writes fewer than 100 prescriptions during the EHR reporting period. EHR Incentive Program Specification: Percentage of patients seen in the reporting period who had at least one active medication on their medication list that the eligible provider prescribed at least once on or before the last day of the reporting period and for whom a licensed healthcare professional used CPOE to generate a prescription at least once during the reporting period. This report may be used only by those eligible providers who meet the three (3) conditions set forth in CMS FAQ MU_Stg1_01_FC_CPOEMedOrders_DenomCalc2.rpt Count 1 for every patient seen by the eligible provider and where the patient's chart has at least one active medication authorized by the eligible provider and entered as a medication order prior to the end of the reporting period. seen by - see Seen by on page 7, for QRS and Crystal Reports. active medication - Any medication recorded in the chart that is a coded drug (and not DME). The onset date must either be blank or on or before the last day of the measure reporting period; if there is an end date, it must be on or after the first day of the measure reporting period. Quality Reporting Services - Uncoded medications may be converted to coded medications if a free text medication entry can be mapped to a coded medication. 15

18 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Numerator Exclusion medication order - A prescription for a coded medication (and not a DME) entered into the chart on or before the last day of the reporting period using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone, Handwritten. Of the patients in the denominator, count 1 for every patient where the patient's chart has at least one prescription that was a CPOE medication order, signed by a qualifying user within the measurement period. CPOE medication order - A prescription for a coded medication (and not a DME) entered into the chart during the reporting period using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone. qualifying user - Equivalent to the CMS term licensed healthcare professional. In the application, this is indicated by the user s assigned Job Title. licensed healthcare professional - The signed by user's Job Title in the application must contain one of the following words at the time the measure report is printed: License, Physician, Resident, Medical Director, or Nurse. QRS report - Whether a provider is considered a licensed healthcare professional is assessed on the last extract date during the reporting period, which is at the end of the reporting period by default. Count 1 for every prescription for a coded medication (not DME) that was entered as a medication order and written by the eligible provider during the measurement period. written by - Eligible provider is the user selected as Authorized By for the prescription. medication order - A prescription for a coded medication (and not a DME) entered into the chart using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone or Handwritten. Note: If the exclusion count is less than 100, the status column in the report will say "excluded." Setup, workflows, and best practices Workflows Setup 1 Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. 2 Confirm or modify user Job Titles. If necessary, you can create new or modify existing Job Titles and assign them to providers to capture all licensed providers in your organization. Go to Setup > Settings > System > Users > Job Titles. 3 Customize report template. If necessary, modify user job title selection criteria to include custom job titles or search for additional strings. Prescribe Medication, Refill Medication, Remove Medication Note that User who enters the prescription record does not have to be a licensed healthcare professional User who signs the prescription must be a licensed healthcare professional To receive MU credit, an eligible provider must be the Authorizing Provider on the prescription These prescribing methods do not qualify as CPOE-defined prescribing methods: Handwritten, Samples Given, Refax, Reprint, Historical. 16

19 CMS Functional Measures - Core 01 CPOE for Medication Orders - Qualification Report (Core) Source Objective References Description File name Denominator Numerator Exclusion 42 CFR 495.6(d)(1) CMS FAQ requires that to use the alternate calculation, eligible providers must meet this criteria: Orders medications for less than 30 percent of patients with a medication in their medication list during the EHR reporting period. Use this report to determine if an eligible provider qualifies to use the alternate denominator calculation (01 CPOE for Medication Orders - Prescribed Medications Only). EHR Incentive Program Specification: Percentage of patients seen in the reporting period who had at least one active medication on their medication list for which the eligible provider prescribed at least once during the reporting period. This report is used to determine if an eligible provider qualifies to use the revised denominator calculation described in CMS FAQ MU_Stg1_01_FC_CPOEMedOrders_DenomCalc2_Qualification.rpt Count 1 for every patient seen by the eligible provider and where the patient's chart has at least one active medication. seen by - see Seen by on page 7, for QRS and Crystal Reports. active medication - Any medication recorded in the chart that is a coded drug (and not DME). The onset date must either be blank or on or before the last day of the measure reporting period; if there is an end date, it must be on or after the first day of the measure reporting period. QRS report - Uncoded medications may be converted to coded medications if a free text medication entry can be mapped to a coded medication. Count 1 for every patient in the denominator who had at least one medication order written by the eligible provider during the reporting period. written by - Eligible provider is the user selected as Authorized By for the prescription. medication order - A prescription for a coded medication (and not a DME) entered into the chart using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone, Handwritten. Count 1 for every prescription for a coded medication (not DME) that was entered as a medication order and written by the eligible provider and signed in the chart during the measurement period. written by - Eligible provider is the user selected as Authorized By for the prescription. medication order - A prescription for a coded medication (and not a DME) entered into the chart using one of the following Prescribing Methods available within the application: Electronic, Fax to pharmacy, Print then fax to pharmacy, Print then give to patient, Print then mail to patient, Print then mail to pharmacy, Telephone, Handwritten. Note: If the exclusion count is less than 100, the status column in the report will say "excluded." 17

20 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports Setup, workflows, and best practices Setup Workflows Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Prescribe Medication, Refill Medication, Remove Medication Note that User who enters the prescription record does not have to be a licensed healthcare professional To receive MU credit, an eligible provider must be the Authorizing Provider on the prescription 18

21 CMS Functional Measures - Core 02 Use Drug-drug / Drug-allergy Interaction-checking (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(2) Yes/No Attestation Only Implement drug-drug and drug-allergy interaction checks. The eligible provider has enabled this functionality for the entire EHR reporting period. None EHR Incentive Program Specification: Setup, workflows, and best practices Setup Workflows Best practices Interaction checking is always enabled and active in the product; it cannot be disabled and requires no special configuration. Prescribe Medication, Refill Medication, Change/Remove Medication While the application is able to check interactions between medications, medication allergies, and medications with diagnosis/age/gender, this measure only considers its ability to display interaction checking between two medications or a medication and an active medication allergy. Centricity EMR permits the organization to set an enterprise-wide level of severity for an interaction that requires the user to manually acknowledge and override the interaction to produce a prescription for a medication. This feature complies with the requirements for meeting this measure. GE recommends providers routinely review and acknowledge when an indicated medication/medication, allergy/medication interaction occurs. 19

22 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 03 Maintain Problem List (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(3) Maintain an up-to-date problem list of current and active diagnoses. More than 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data. None EHR Incentive Program Specification: Description File name Denominator Numerator Percentage of patients seen in the reporting period whose problem list was maintained before or during the reporting period. MU_Stg1_03_FC_ProblemList.rpt Count 1 for every patient seen by the eligible provider. seen by - see Seen by on page 7, for QRS and Crystal Reports. Of the patients in the denominator, count 1 for every patient where the patient's chart has at least one active problem or an indication of No Known Problem (NKPROB). active problem - A problem recorded in the chart of any problem type (except Status Post), where the problem code begins with 'ICD-'. The onset date must either be blank or on or before the last day of the measure reporting period; if there is an end date, it must be on or after the first day of the measure reporting period. The problem code field must start with 'ICD-'. SNOMED codes are not considered. No Known Problem - Indicated in the application when the latest recorded NKPROB observation in the patient's chart has a value of 'T' at any time on or before the last day of the reporting period. QRS report - Does not explicitly exclude problems with type Status Post. Custom Procedures with a code starting with 'ICD-' (where Status Post typically applies) are accepted. Additional values for NKPROB indicating no known problems are accepted. GE recommends you use 'T', the default value when This patient has no known problems (NKPROB) is checked in the application. Setup, workflows, and best practices Workflows Setup Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Maintain Problem list Add / Change Problems (any problem type except Status Post; must include 'ICD-' code) Check No Known Problems Generate Orders Under Potential Diagnoses list, select or add a new Problem to associate with the order. Check Add to Patient Problem List to ensure problems associated with orders are counted. For every patient seen, one of these conditions must be present to count for the eligible provider: 20

23 CMS Functional Measures - Core At least one problem on the Problem List with either no start date, or a start date before the end of the reporting period. This Patient Has No Known Problems (NKPROB) is checked before the end of the reporting period. Best practices Review and update all patients active problems each visit to assure the accuracy and currency of the Active Problem list. All problems must have 'ICD-' codes. Problems with onset dates prior to the end of the reporting period (or no start date) are counted as active problems. It does not matter who added the problem(s) to the list. Measure calculation is not affected when Problem List Reviewed During This Update is checked. If all the patient s problems are resolved, check This Patient Has No Known Problems (NKPROB) when the last problem is removed. 21

24 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 04 e-prescribing (erx) (Core) Source Objective Measure Exclusion References Description File name Denominator Numerator Exclusion 42 CFR 495.6(d)(4) Generate and transmit permissible prescriptions electronically (erx). More than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology. Any EP who writes fewer than 100 prescriptions during the EHR reporting period. EHR Incentive Program Specification: Percentage of permissible prescriptions that were transmitted electronically during the reporting period. MU_Stg1_04_FC_eRX.rpt Count 1 for every permissible prescription written by the eligible provider during the measure reporting period. written by - The eligible provider is the user selected in the application as Authorized By for the prescription. permissible prescription - A prescription for a prescription-only (not OTC - over the counter) coded medication (and not DME) entered into the chart using one of the following prescribing methods available within the application: Electronic Fax to pharmacy Print then fax to pharmacy Print then give to patient Print then mail to patient Print then mail to pharmacy Telephone Handwritten Note: Controlled substances class code 1-5 are not included. QRS report - Uncoded medications may be converted to coded medications if a free text medication entry can be mapped to a coded medication. Of the prescriptions in the denominator, count 1 for each where prescribing method is Electronic. Count 1 for every prescription for a coded drug medication (and not DME) written by the eligible provider as a medication order and signed in the chart during the measure reporting period. written by - The eligible provider is the user selected as Authorized By for the prescription. medication order - A prescription for a coded medication (and not a DME) entered into the chart using one of the following Prescribing Methods available within the application: Electronic Fax to pharmacy Print then fax to pharmacy Print then give to patient Print then mail to patient Print then mail to pharmacy Telephone 22

25 CMS Functional Measures - Core Handwritten Setup, workflows, and best practices Setup 1 Implement Centricity Advanced eprescribing - configure application and users for eprescribing. 2 Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Workflows Best practices (With eprescribing enabled) Prescribe medication, Refill medication Set the eligible provider as Authorized By when producing a prescription for medications permitted to be transmitted electronically. The measure does not assume that all medications can be electronically prescribed. Use prescribing method of Electronic for prescriptions that are not for Controlled substances Over the counter (OTC) medications Over the counter supplies The product meets all requirements with Centricity Advanced eprescribing. For details, see What s New in Centricity EMR. Always set the eligible provider as Authorized By when completing a prescription request. Use the Electronic prescribing method whenever possible for medications permitted to be transmitted electronically. 23

26 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 05 Active Medication List (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(5) Maintain active medication list. More than 80 percent of all unique patients seen by the EP have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data. None EHR Incentive Program Specification: Description File name Denominator Numerator Percentage of patients seen in the reporting period whose medication list was maintained before or during the reporting period MU_Stg1_05_FC_MedList.rpt Count 1 for every patients seen by the eligible provider. seen by - see Seen by on page 7, for QRS and Crystal Reports. Of the patients in the denominator, count 1 for every patient where the patient's chart has at least one active medication or an indication of No Known Medication (NKMED). active medication - Any medication recorded in the chart, coded or uncoded, drug or DME, and so on. The onset date must either be blank or on or before the last day of the measure reporting period; if there is an end date, it must be on or after the first day of the measure reporting period. No Known Medication - Indicated in the application when the latest recorded NKMED observation in the patient's chart has a value of 'T' at any time on or before the last day of the reporting period. QRS report: Additional values for NKMED indicating no known medications are accepted. GE recommends you use 'T', the default value when This Patient Takes No Known Medications (NKMED) is checked in the application. Setup, workflows, and best practices Setup Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Workflows Maintain Medication list, Add / Change Medication, Record No Known Medication For every patient seen, one of these conditions must be present to count for the eligible provider: At least one medication on the Medication list with either no start date, or a start date before the end of the reporting period. This Patient Takes No Known Medications (NKMED) is checked before the end of the reporting period. Best practices Review and update all patients active medications each visit to assure the accuracy and currency of the Medication list. Medications with onset dates prior to the end of the reporting period (or no start date) are counted as active medications. It does not matter who added the medication(s) to the list. 24

27 CMS Functional Measures - Core Measure calculation is not affected when Medications List Reviewed During This Update is checked. If all patient s medications are discontinued or ceased, check This Patient Takes No Known Medications (NKMED) when the last medications is removed. 25

28 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 06 Medication Allergy List (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(6) Maintain active medication allergy list. More than 80 percent of all unique patients seen by the EP have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data. None EHR Incentive Program Specification: Description File name Denominator Numerator Percentage of patients seen in the reporting period whose allergy list was maintained before or during the reporting period. MU_Stg1_06_FC_MedAllergyList.rpt Count 1 for every patient seen by the eligible provider. seen by - see Seen by on page 7, for QRS and Crystal Reports. Of the patients in the denominator, count 1 for every patient where the patient's chart has at least one active medication allergy or other allergy or an indication of No Known Allergy (NKA). active allergy - Any allergy recorded in the chart, including food allergies, environmental allergies, uncoded (custom) allergies, and medication allergies. The onset date must either be blank or on or before the last day of the measure reporting period; if there is an end date, it must be on or after the first day of the measure reporting period. No Known Allergy - Indicated in the application when the latest recorded NKA observation in the patient's chart has a value of 'T' at any time on or before the last day of the reporting period. In determining No Known Allergy, the system does not distinguish between types of allergies. Therefore, it cannot report only No Known Medication Allergies if other allergies are indicated in the system. QRS report: Additional values for NKA indicating no known allergies are accepted. GE recommends you use 'T', the default value when This Patient Has No Known Allergies or Adverse Reactions (NKA) is checked in the application. Currently, the active status of an allergy is assessed at the date of the last MQIC data extract. For 3-month reporting periods the last extract date is synonymous with the last day of the reporting period. Setup, workflows, and best practices Setup Workflows Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Maintain Allergies list, Add / Change Allergy, Record No Known Allergy For every patient seen, one of these conditions must be present to count for the eligible provider: At least one allergy (medication or non-medication) on the Allergies and Adverse Reactions list with either no start date, or a start date before the end of the reporting period. This Patient has No Known Allergies or Adverse Reactions (NKA) is checked before the end of the reporting period. 26

29 CMS Functional Measures - Core Best practices Review and update all patients active allergies each visit to assure the accuracy and currency of the Allergies and Adverse Reactions list. Allergies with onset dates prior to the end of the reporting period (or no start date) are counted as active allergies. It does not matter who added the allerg(ies) to the list. Measure calculation is not affected when Allergies and Adverse Reactions List Reviewed During This Update is checked. If all patient s allergies are resolved, check This Patient has No Known Allergies or Adverse Reactions (NKA) when the last allergy is removed. 27

30 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 07 Record Demographics (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(7) Record all of the following demographics: Preferred language Gender Race Ethnicity Date of birth More than 50 percent of all unique patients seen by the EP have demographics recorded as structured data. None EHR Incentive Program Specification: Description File name Denominator Numerator Percentage of patients seen in the reporting period for whom the required demographics (preferred language, gender, race, ethnicity, and date of birth) were recorded in patient registration before or during the reporting period. MU_Stg1_07_FC_Demographics.rpt Count 1 for every patient seen by the eligible provider. seen by - see Seen by on page 7, for QRS and Crystal Reports. Of the patients in the denominator, count 1 for every patient for whom all required demographics are recorded with OMB specific values. required demographics - Include the following attributes: Date of Birth, Gender, Preferred Language, Race, Ethnicity. Race: Any custom value or default system values except: Hispanic, Other, and Multiracial. The OMB values include: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Ethnicity: The following default and custom values are the only acceptable values. Default system values: Hispanic or Latino Non Hispanic or Latino Other or Undetermined Custom values: Declined Not Hispanic or Latino Non-hispanic or Latino 28

31 CMS Functional Measures - Core Nonhispanic or Latino recorded - at the time the measure report is printed. QRS report: GE recommends you record demographics in the application Registration module. Otherwise, enter values using observation terms in the observation groups RACE MU, ETHNICITY MU, and LANGUAGE. Values for race, ethnicity, preferred language, gender, and date of birth from the application registration module are assessed on the last extract date for the reporting period, which is at the end of the reporting period by default. Obs groups and demographic data can only be obtained through the chart module and not the billing system. Setup, workflows, and best practices Setup 1 Configure Race/Ethnicity values. Set up, add or change Race and Ethnicity values in Setup Settings > Registration > Ethnicity and Setup Settings > Registration > Race. 2 Avoid using default Race values Hispanic, Other, Multiracial. These default values are not compliant with OMB. To record Multiracial, create a custom value containing the component OMB races (for example, "Asian/White"). Workflows Best practices 3 Modify your Check-In /Registration workflow to capture Ethnicity value where needed. 4 Set up LinkLogic. LinkLogic automatically imports both values. 5 Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Register/Schedule patient, New /Change patient The system is pre-populated with values that meet EHR Incentive Specification guidelines: Race and ethnicity codes should follow current federal standards published by the Office of Management and Budget ( Document Date of Birth, Gender, Preferred Language, Race, Ethnicity values for patient in Registration manually or through electronic interface exchange of demographics data. Modify Check-in/Registration workflows to require staff to ask about race, ethnicity, and language preference in a professional and sensitive manner. If patient declines to provide Race or Ethnicity or if collection of this information is prohibited by law, select list option Undetermined for Race and Other or Undetermined for Ethnicity. These values meet the goal of structured data. Note. Historic information is not counted. Caution. Your system may include default values that do not map to OMB categories and are not counted to meet Meaningful Use criteria. New installations - Default values not mapped to OMB categories can be removed. Existing installations - If a value has been used for a patient, it cannot be removed from the system until all instances of its use have been removed from Registration. Recommended. If a patient wants to record more than one race, OMB requires that each race value be indicated separately. If necessary, set up custom race values, so the Registration list includes all races that might apply to a patient of more than one race. For example: Black/White or White/Asian or Asian/Hawaiian/White. Data exchange. Additional interface data may need to be added to the producing system file to assist with capturing data in the application. If manually updating the registration items, appropriate privileges must be enabled to complete this task. If the patient refuses to answer questions about race and ethnicity documenting undetermined qualifies for meeting this measure. Any value means you are in compliance with the measure. 29

32 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 08 Record Vital Signs (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(8) Record and chart changes in the following vital signs: Height Weight Blood pressure Calculate and display body mass index (BMI) Plot and display growth charts for children 2-20 years, including BMI More than 50 percent of all unique patients age 2 and over seen by the eligible provider, height, weight and blood pressure are recorded as structured data. Any EP who either see no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice. EHR Incentive Program Specification: Description File name Denominator Numerator Percentage of patients seen in the reporting period for whom the required vital signs (height, weight, and blood pressure) were recorded in their chart before or during the reporting period. MU_Stg1_08_FC_VitalSigns.rpt Count 1 for every patient that meets the qualifying age and is seen by the eligible provider. seen by - see Seen by on page 7, for QRS and Crystal Reports. qualifying age - Includes any patient 2 years old or older at the time the patient is seen by the eligible provider. Of the patients in the denominator, count 1 for every patient for whom all required vitals are recorded at least once in the patient's chart recorded - The required vitals entry date must be on or before the last day of the measure reporting period. required vitals - Includes height, weight, and blood pressure only as specified in the CMS measure. Crystal Report: - Searches for the observations HEIGHT, Height (cm), WEIGHT, Weight (kg), BP DIASTOLIC, BP SYSTOLIC. BP SYS STAND, BP SYS LYING, BP DIA STAND, BP DIA LYING. QRS report - Searches for additional observations in these observation groups: BP DIASTOLIC, BP SYSTOLIC, HEIGHT, WEIGHT (multiple terms in each group). Data is de-identified, with only the patient month and year of birth available. This may affect which patients meet the age criteria for a particular reporting period. Exclusion The eligible provider is not listed in the report if the eligible provider's denominator value is 0 (zero), which indicates that the eligible provider may meet the exclusion criteria. Setup, workflows, and best practices Setup 1 Confirm supported clinical content. Import latest clinical kits and confirm supported encounter forms are associated with your encounter types/documents. 30

33 CMS Functional Measures - Core Workflows Best practices 2 Confirm custom forms use observation terms noted above. 3 Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. 4 The Patient Encounter (MU) document view is hidden by default but can be modified in Go > Setup > Settings > Chart > Document Views. Make sure you import the upgrade.ckt clinical kit before attempting to modify this view. 5 Customize report template. Modify report template in Crystal Reports to include custom observation term if needed, or consider using Quality Reporting Services (QRS) which includes many additional terms. Update Chart Use encounter forms (any GE or CCC vital signs encounter form that uses supported observations). Growth charts/bmi calculation: Only height, weight, and blood pressure are required. The certified EHR technology will calculate BMI and the growth chart if applicable to patient based on age. Note: Required vitals need not be updated at every patient encounter. According to the EHR Incentive Program Specification: Height, weight, and blood pressure do not have to be updated by the eligible provider at every patient encounter. The eligible provider can make the determination based on the patient's individual circumstances as to whether height, weight, and blood pressure need to be updated. When clinically appropriate, record required height, weight, and blood pressure vitals as part of a patient visit. All standard vital signs encounter forms assist in documenting and recording these vitals. This measure references BMI (Body Mass Index) and growth cart data available for patients between the ages of 2 and 20 years. BMI is automatically calculated using entered weight and height. The Growth Chart uses BMI plotted on the chart/graph. This functionality available for patients between 2 and 20 years old meets current requirements for this measure. If creating custom content or editing a vital signs form, store the data using the Observation terms: HEIGHT, Height (cm), WEIGHT, Weight (kg), BP DIASTOLIC, BP SYSTOLIC. Note: BP supine and BP standing do not store data in the BP SYSTOLIC and BP DIASTOLIC observation terms. Ensure that your users are using the BP sitting vital signs or modify the form to change the observation terms for these values. 31

34 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 09 Record Smoking Status (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(9) Record smoking status for patients 13 years old or older. More than 50 percent of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data. Any EP who sees no patients 13 years or older. EHR Incentive Program Specification: Description File name Denominator Percentage of patients seen in the reporting period for whom smoking status was recorded in their chart before or during the reporting period. MU_Stg1_09_FC_SmokingStatus.rpt Count 1 for every patient that meets the qualifying age and is seen by the eligible provider. seen by - see Seen by on page 7, for QRS and Crystal Reports. qualifying age - Includes any patient 13 years old or older at the time the patient is seen by the eligible provider. Numerator Of the patients in the denominator, count 1 for every patient for whom a smoke status was recorded and signed in the patient's chart using smoke status observation terms with ONC-specified values. recorded - the smoking status entry date is on or before the last day of the measure reporting period. smoke status - searches for the observations Cigaret smkg, SMOK STATUS, smokes, smoking hx, HX CIGARETTE, SMKSTATOVR13. ONC-specified values current every day smoker current some day smoker former smoker never smoker unknown if ever smoked smoker, current status unknown Accepted variations (custom values): smoker - current status unknown smoker current status unknown smoker-current status unknown smoker- current status unknown smoker,current status unknown smoker, current status unknown smoker:current status unknown smoker: current status unknown QRS report: Text strings for smoking status that begin with one of the values listed above are accepted. Additional text following one of these strings will not exclude the term. Data is de-identified, with only the patient month and year of birth available. This may affect which patients meet the age criteria for a particular reporting period. Exclusion The eligible provider is not listed in the report if the eligible provider's denominator value is 0 (zero), which indicates that the eligible provider may meet the exclusion criteria. 32

35 CMS Functional Measures - Core Setup, workflows, and best practices Setup 1 Confirm supported clinical content. Import latest clinical kits and confirm supported encounter forms are associated with your encounter types/documents. 2 Set up Document Types. Add any custom encounter documents to Patient Encounter (MU) global chart document view. See Modifying the Patient Encounter (MU) document view on page 8. Workflows Best practices 3 The Patient Encounter (MU) document view is hidden by default but can be modified in Go > Setup > Settings > Chart > Document Views. Make sure you import the upgrade.ckt clinical kit before attempting to modify this view. 4 Customize report template. Modify report template in Crystal Reports to include custom observation term if needed, or consider using Quality Reporting Services (QRS) which includes many additional terms. Current product captures smoking status on the Risk Factors form. In FH-SH-CCC form, the smoking status field includes more detailed values specified in the final ARRA regulation 45CFR (f). Update Chart - Only use encounter forms that include supported observations and observation values. Smoking Status must be recorded before the end of the measure reporting period but can occur before the beginning of the period. This design is based on the EHR Incentive Program specification: If this information is already in the medical record available through certified EHR technology, an inquiry does not need to be made every time a provider sees a patient 13 years old or older. The frequency of updating this information is left to the provider and guidance is provided already from several sources in the medical community. During routine patient visits, clinical interaction regarding smoking, and smoking cessation can be documented by any clinician working with the patient. The report does not count how often the patient is asked about smoking status. If a patient over 13 has been asked this question and the answer is recorded using a valid observation term, the patient counts toward meeting the measure if they are seen within the reporting period regardless of whether they were asked during the reporting period. Use the Social History or Risk Factor Form during the interaction with the patient to record their response to smoking status and smoking questions. You can use the form for patients of any age, but only patients over the age of 13 are counted for this measure. If using alternative content or editing the FH-SH form component, use the observation term SMOK STATUS. 33

37 CMS Functional Measures - Core 11 Implement One Clinical Decision Support Rule (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(11) Yes/No Attestation Only Implement one clinical decision support rules relevant to specialty or high clinical priority along with the ability to track compliance with that rule. Implement one clinical decision support rule. Providers have considerable flexibility in meeting this measure. They need only attest they are using a clinical decision support rule. For example, anything that provides a notification will be counted, including a pop-up alert that requires a response or an indicator on a form showing an immunization, exam, or test due. None EHR Incentive Program Specification: Setup, workflows, and best practices Setup Workflows Best practices Optionally log decision support user actions. Although not required for attestation, to see how user decision support actions are captured by the system, go to Setup > Settings > System > Auditing and confirm that MEL Decision Support is in the Log Audit Events column. Various workflows support this measure including: Using Pop Up Alerts on charts that have been designated as needing a clinical intervention based on a treatment deficiency. Using Protocols for USPS or Treatment/Diagnostic related treatment interventions. Using content that alerts or interacts with the provider based on clinical treatment needs or deficiencies. You do not need to track these actions to fulfill this measure requirement. The application provides MEL functions UserYesNo and UserOK in encounter forms, document templates, and patient banners to support decision support rules. System auditing automatically logs user responses to alerts and care suggestions created with MEL decision support functions. You can optionally track, record, and generate reports on the number of alerts responded to by a user. 35

38 Using Centricity Electronic Medical Record Meaningful Use and Quality Reports 12 Provide Electronic Copy of Health Information (Core) Source Objective Measure Exclusion References 42 CFR 495.6(d)(12) Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, medication allergies) upon request. More than 50 percent of all patients who request an electronic copy of their health information are provided it within 3 business days. Any EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period. EHR Incentive Program Specification: Description File name Denominator Numerator Percentage of patient requests for an electronic copy of their health information that were provided within 3 business days of the request. MU_Stg1_12_FC_eCopyHealhInfo.rpt Count 1 for each recorded qualifying request to which the eligible provider is linked. linked provider Crystal Reports login name (ROI AUTH LN) of the user selected from the Authorized By (ROI AUTH) field on the Patient Authorization Form. (Entering the user name manually to match DOES NOT push required ROI AUTH LN term to the chart.) QRS MQIC is not able to utilize the 'authorizing provider' field. The responsible provider and first signer on the document containing the required obs terms are given credit for the patient. No specific document type is necessary. qualifying request Date Request Received (ROI DTE RCVD) must be within the measure reporting period up to 4 business days prior to the last day of the reporting period Purpose of Disclosure (ROI REASON) must be copy for patient. Sent Via (ROI METHOD) must be electronic. recorded - Linked provider and qualifying request observation terms must be on the same document. Note: Appends do not count as same document. Of the qualifying requests in the denominator, count 1 for each request that was fulfilled in the required time frame. fulfilled - Date Sent must be specified on the same document as the request for one or more disclosed information types (ROI AL SD DT, ROI CR SD DT, ROI DA SD DT, ROI DD SD DT, ROI DTE SENT, ROI EN SD DT, ROI ER SD DT, ROI GT SD DT, ROI HA SD DT, ROI IR SD DT, ROI LR SD DT, ROI MH SD DT, ROI ML SD DT, ROI OR SD DT, ROI OT SD DT, ROI PL SD DT, ROI RR SD DT, ROI XR SD DT). QRS report: Currently MQIC only recognizes one observation term for the date the health information was delivered (ROI ER SD DT). required time frame - Within 3 business days of the request. Exclusion The eligible provider is not listed in the report if the eligible provider's denominator value is 0 (zero), which may indicate that the eligible provider may meet the exclusion criteria. 36

39 CMS Functional Measures - Core Setup, workflows, and best practices Setup Workflows Confirm and use Patient Authorization (release of information) form to capture information about requests that can be reported Important: the following information describes how to use the application for Meaningful Use reporting only. It does not address usage and process to be in compliance with HIPAA rules for releasing PHI. This authorization form is located in Clinkits/BasicPr/Items/FormComp /AuthForm/AUTHFORM.CKT Best practices This authorization form is enhanced so you can also use it to capture a patient's request for an electronic copy of their health information and the date of fulfillment. The form can also be used for its intended purpose in other contexts. Entries required for calculation include: - Information Disclosed - if you are using QRS reports, select Entire Record. If you are using Crystal Reports, you can select one or more options. - Date Sent - must be selected - Purpose of Disclosure - select Copy for patient - Authorized By - always select the eligible provider for the measure from the Authorized By list. (Typing the name manually to match does not push the required observation term ROI AUTH LN to the chart.) - Sent Via - select Electronic - Date Request Received - must be selected Note: Always use the calendar utility by each date field to select and enter the date. Or if entering manually, use required slash delimiters to format as a date value, for example, 12/13/2011. If you enter an unformatted date ( or ), the form does not correct the error. Delivery mechanisms: Generate Chart Summary in CCD format (from Actions menu) and save it to electronic media (portable storage device, CD) Send CCD Chart Summary to patient via Secure Messaging These options meet the EHR Incentive Program Specification requirements that data be structured to CCD standards and human readable. Generate and send clinical summary in CCD format to other systems via Secure Messaging, SMIM secure , or HIE. You may send by regular ONLY if the CCD file is 37

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